TIFFE/CAMHD
Documentation Training
GOALS
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To ensure clinicians are adherent to
CAMHD/TIFFE documentation
requirements (i.e., format, timeline,
structure, etc).
To ensure clinicians produce/provide
quality of documentation (i.e.,
individualized to each client/family,
S.M.A.R.T.).
AGENDA
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Pre-test
Required Intake Forms.
Mental Health Treatment Plan (MHTP).
Progress Notes
Monthly Treatment and Progress
Summary.
Sentinel Events Report.
Annual Summary Reports.
Behavioral Plan.
Discharge Summary.
INTAKE FORMS
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Handout and Sample.
THE PURPOSES of MHTP
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Contract agreement between
client and provider.
Guide the course of treatment
for identified problems or issues.
Evaluate the client’s progress in
meeting specified goals and
objectives.
Mean of communication
between providers.
STEPS IN DEVELOPING MHTP
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Gather information
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Review available information (reports, CSP,
medical records, court records, school records,
etc.).
Interview process (youth, caregivers/guardians,
other provider/treatment team members, etc.).
Develop case formulation
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Identify clients’ current situations and what they
want to accomplish.
Determine the most effective and appropriate
ways to help clients achieve their goals.
Identify possible barriers in accomplishing the
goals.
Determine an estimated time to accomplish the
goals.
REQUIRED COMPONENTS
OF MHTP
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Client’s DSM-TR IV diagnosis code(s)
consistent with the assessment(s).
Goals and measurable objectives.
Target dates.
Appropriate strategies/interventions
(Best Practices).
A list of the services to be provided/who
will provide the services.
Crisis plan.
Transition/Discharge Plan.
REQUIRED COMPONENTS
OF MHTP
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Signature of client (when appropriate).
Signature of the client’s parents,
guardian, or legal custodian.
Signature of the treatment team
members who participated in the
development of the plan (at minimum
MHCC).
Date of start and end of services.
MHTP

Goal (WHAT))
 The end point of therapeutic work (Desired
outcome).
 Example of Goals:
 Family = Develop positive family interaction.
 School = Improve school/academic
performance.
 Community = Increase involvement in
community activity.
 Individual = Improve problem solving skills.
 Social/Peer = Develop and maintain positive
peer interactions.
 Legal = Maintain no involvement in law
violation.
MHTP
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Objective (HOW)
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Step(s) in achieving the goal.
S pecific
M easurable
A ttainable
R ealistic
T ime-limited
MTPS (Objective Examples)
Domain
Goals
Measurable
Objectives
Individual
Develop ability to
communicate and
verbalize feelings.
Joey will be able to identify
and label his feelings 90% of
the time for a period of 3
months.
Joey will be able to verbalize
his feelings to trusted
adults/peers 75% of the time
for a period of 3 months.
Joey will use an “I” statement
message to communicate his
feelings to trusted
adults/peers 75% of the time
for a period of 3 months.
MHTP
(STRATEGIES/INTERVENTIONS
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Based on best practice.
Need to consider youth’s
diagnosis/issues.
Need to consider youth/family’s
cultural in identifying appropriate
interventions.
Need to consider youth/family’s
resources or lack of resources.
Need to consider youth/family
readiness for change.
REQUIRED COMPONENTS
OF MHTP
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Crisis Planning:
Address settings events, triggers,
preventive as well as reactive intervention.
Must focus on early intervention.
Transition/Discharge Plan:
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Begin at the initial meeting.
Describe the supports and necessary services
for successful and smooth transition.
Identify the criteria for transition or discharged
based on MHTP goals and objectives.
Need to include contigency plan.
MHTP needs to be completed within 10
days of intake.
CHARACTERISTICS of
GOOD MHTP
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Individualized to each client/family.
Directly linked to achieving goals in a client’s IEP
or/and CSP.
Identify client/family’s challenges as well as
strengths areas.
Based on strengths, and needs driven.
Must be developed with youth (when appropriate)
and parent/guardian involvement.
Written in client/family language.
Problems/issues are stated using positive language.
Goals/objectives/interventions are appropriate to the
client’s diagnosis, age, culture, strengths, abilities,
preferences, and needs expressed by the
client/family.
Goals/objectives/interventions need to be
attainable, realistic, measureable.
MHTP
GROUP ACTIVITY
“Creating A Treatment Plan”
PROGRESS NOTES
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Purpose
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Serve as documentation of treatment.
Track therapy progress.
Essential part of therapy process.
Ensure quality assurance.
Format (DAP)
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D escription:
A ssessment: This section is where you assess,
in descriptive terms, the client’s performance
during the session and/or the session itself.
P lan: The final section of your DAP notes is
where you outline the course of treatment, after
considering the information you gathered during
the session. Next session date.
PROGRESS NOTES
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Things to consider when writing
progress notes:
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Who are you writing your progress
notes for?
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Yourself (clinician)
TIFFE (supervisor/program manager/clinical
director)
CAMHD (care coordinator, auditor, QA
people)
Who will have access to your progress
notes?
PROGRESS NOTES
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Who will have access to your progress
notes?
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Agency (Supervisor, Clinical Director, etc.).
Client/Caregiver
CAMHD (care coordinator, chief branch,
CAMHD psychologist, etc)
Court system (probation officer, judge, etc.)
Other agency/provider involves in client’s
therapy (i.e., teacher, CPS, individual
therapist, psychistrist, etc).
Progress Notes
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How much information need to be
included?
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Need to include adequate information in
regard what occur in therapy session related
to therapy goals/process.
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What are the issues being address?
What are the goals being work on.?
How do the issues or goals are being
address (specific strategies/intervention)?
How does youth response to intervention?
What progress does youth make (describe
the progress)?
Is there any issues that might hinder the
youth’s progress?
How does this issue is being address?
PROGRESS NOTES
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What types of information need be
included?
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Only include information, issues, or
problems that have direct impact on
youth’s level functioning or directly
related to treatment.
PROGRESS NOTES
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Who Relies On Your Documentation:
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Treatment Team members
Referral Sources
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To advocate for the most appropriate and
effective care for client.
Employers
Other Payors
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To justify need for continued treatment, need
for admission, demonstrate appropriateness
and cost-effectiveness of care, demonstrate
all billable services were provided.
PROGRESS NOTES
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Samples of good progress
notes.
Handouts.
Practice writing progress notes.
MONTHLY TREATMENT
AND PROGRESS SUMMARY
SENTINEL EVENTS
REPORTS
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Purpose
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To establish uniform guidelines for a reporting
system that is designed to track and document
sentinel events and the follow-up of the events
reported by the CAMHD Branches and
contracted provider agencies (provider).
Definitions
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Sentinel Event: An occurrence involving serious
physical or psychological harm to anyone or the
risk thereof, as defined under the categories of
sentinel event codes and definitions.
Critical Event: Events involving serious injury or
death, suicidal attempts, sexual misconduct,
allegations of staff abuse or misconduct.
SENTINEL EVENTS
REPORTS
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Procedure
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When a sentinel event occurs the
provider:
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Notify the youth’s legal guardian, and MHCC
within 24 hrs of the occurrence of the
sentinel event, either by phone of fax.
Complete CAMHD’s sentinel event report
form (signed by TIFFE’s clinical director or
supervisor on site).
Sentinel event report (signed by clinical
director/supervisor on site) need to be faxed
to SES and MHCC within 72 hours of the
sentinel event.
SUMMARY ANNUAL
ASSESSMENT
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Purpose:
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Address significant changes, current
status and consequent
recommendation.
Information to be included:
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Measures of youth’s behavior and
functioning
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CAFAS/PECFAS and ASEBA checklist for
parents, teacher and youth’s self report form
need to be included.
Structure/format (see handout).
Write a progress notes indicating that
you are working on Summary Annual
Assessment (for billing purpose).
DISCHARGED SUMMARY
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Written discharge summary must be
submitted to appropriate CAMHD
Branches within ONE week of
service termination.
Post CAFAS/PECFAS needs to be
completed and turn in with your D/C
summary.
CAFAS/PECFAS needs to include
pre/post score on individual as well
as family functioning.
D/C date is the last session you had
with youth/family.
SENTINEL EVENT REPORT
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Sentinel events Handouts.
Sample.
Closing
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Q&A
Post-test
Evaluation